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Alt 1" SAN JOAQUIN LOCAL HEALTH DISrkICT <br /> F ICE USE: 1601 E. Hazelton Ave. , :'tor.kton, CA 952u5 Per 11o.7g <br /> Telephone: (209) 466-67Fil <br /> ----� AonLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT ID-1te Issaed y-S'-7� <br /> This Permit ! x ires 1 tear From Date Issued <br /> -- .Comp ete In r3PTICatT--� <br /> Application is hereby made to the San Joaquin Local Health District for a Permit 0 constrX t <br /> and/or 4nsta'fl the work herein described. This application is mdde in compliance with Sat <br /> .oan.:in County !Irdinance ':u. 1862 and the Rules and Regulations of the San Joaquin local Realth <br /> .listr,ct. <br /> EXACT STREET ADDRESS //z? e C ����� s r/�� CITY/TOWN <br /> t` <br /> " _ _ _ <br /> '4l Owner's Name A4�,r-,k. _ ,r ,P --�_ Phone <br /> Address �/ C �o ��c/`. Ci ty W <br /> Contractor's Name-t License�jJ?t 7�-i Phone 5�4 } - 76 7 <br /> IS CERTIFICATE OF WOI'.Y11AN'S (,:1"1 .NSATIO'! I'ISURANCE Ott FILO WIT► SJ111D? YES X .140 <br /> TYPE OF WORK (Check) : NEW WELL❑ DEEPEN 0 RECONDITION ❑ DESTRUCTION❑ <br /> WELL CHLORINATION 0 WELL ABANDONMENT p OTHER❑ -- <br /> PUMP INSTALLATION ❑ PUMP REPAIR❑ PUMP REPLACEMENT EM <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPTS-AU7rIELD Ca-79L/SEEPAGE STT— OTHER <br /> PROPERTY LINE - PRIVAYr-WESTIC WELL PUBLTC- ESTIC 9=_ S� <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial- —Cable To Dia, of Wel Excavation <br /> =Domestic/private Drilled Dia. of Well Casing �r <br /> -Domestic/public Driven Gauge of Casing <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal ;nsta ed by: <br /> PUMP INSTALLATION: Contractor J , <br /> Type of Pump_ H.P. / <br /> FUMP REPLACEMENT: ®State Work Done 1„,,4 ix ,4 Cie $2,,r• ��� eMl 4�peg <br /> {� PUMP REPAIR: ❑State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procpdure <br /> s <br /> I hereby certify that I have prepared this application and that the work will be done in accordance <br /> with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any person in such manner as to become subject to Workman's Compensation <br /> lays of California." <br /> I WI,.,- CALL FOR A GROUT INSPECT 0 PRIOR TO GROUTING AND A FINAL INSPECTION. <br /> " SIGNED - — TLE: DATE: L= <br /> L ON REVERSE SIDE) <br /> FOR DEPARTMENT USE NL <br /> PHASE I / <br /> APPL-IC�TION ACCEPTED BY C ,✓/ DATE 7d� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III FINAL INSPECTI N <br /> INSPECTION BY DATE_ INSPECTION BY DATFx 7 <br /> EH 1426 Rev. 1?-77 1 /78 2M <br />